Surgical Authorization Form

Client Full Name *

Patient Name *

Phone Number *

Email Address *

I am the owner, or the agent for the owner, of the animal described above and I have the authority to execute this consent. I hereby consent and authorize St. Vital Veterinary Hospital staff to perform:

I understand that there are certain risks and complications associated with any operation or procedure. I further understand that during the course of the operations or procedures, unforeseen conditions & life-threatening medical emergencies may arise that may necessitate the performance of additional procedures. I have been advised of the nature of the service and procedures, as well as the risk involved, and I also realize that results cannot be guaranteed.

If my pet has a life-threatening medical emergency or an unforeseen condition while in the care of St. Vital Veterinary Hospital (check one): *

I DO NOT authorize St. Vital Veterinary Hospital to perform CPR or life saving measures on my pet.
I DO authorize St. Vital Veterinary Hospital to perform measures to stabilize my pet until I can be reached by phone during a life-threatening medical emergency. This will include required medications, intubation, ventilation, manual and CPR. I understand and accept these measures will be at an additional cost to the previous treatment plan. The immediate treatments required to stabilize my pet’s condition including but not limited to, intravenous catheter placement and fluid administration, rapid diagnostic testing and emergency medications may range from $300-$500. Cost of stabilization can exceed this amount in very critical situations.

I authorize the use of appropriate anesthesia and pain relief medication as needed before, during or after the procedure. I understand there are risks associated with the use of any anesthetic or medication.

Pre-anesthetic Blood Screening Consent/Waiver:

We recommend doing a pre-anesthetic blood work panel to tailor your pet’s anesthetic, pain control, and recovery. It also determines anesthesia candidacy. *

Accept
Decline
Already Completed

I understand and assume all responsibility for additional risks/complications resulting from refusal to approve this pre-anesthetic blood work screening for my pet’s safety.

Do you want your pet to receive any of the following forms of identification? *

Tattoo
Microchip
No, thank you

I agree to pay the full amount that is due before the patient is discharged.

Client Signature *

Best Phone Number to Reach You - Please ensure your phone is always on and you are available 24/7. *

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *